Keywords
bile leak - ERCP - spyglass cholangioscopy
A 37-year-old female with no underlying comorbidities was referred for the evaluation
of biliary stricture. She had mild upper abdominal pain for a year without any fever
or jaundice. Magnetic resonance cholangiopancreatography (MRCP) showed a focal lesion
in the left hepatic duct close to primary confluence causing a stricture and bilateral
intrahepatic biliary radicle dilatation. Her routine laboratory tests including liver
function tests were normal. On endoscopic ultrasound, she had bilateral biliary radicle
dilatation and a hilar stricture, the nature of which was not clear. Spyglass cholangioscopy
showed normal common bile duct, irregular mucosa with scarring in the common hepatic
duct, and a nodular hyperemic lesion at the bifurcation, more toward the left duct
([Fig. 1]). SpyBite biopsy was taken from the stricture and the left duct was stented with
a 7 Fr (French) double pigtail plastic stent. Repeated attempts at attaining deep
cannulation of the right duct, using a tapered tip endoscopic retrograde cholangiopancreatography
(ERCP) catheter and a 0.025-inch guidewire with hydrophilic tip, were unsuccessful.
Patient developed right-sided abdominal pain the next day requiring opioid infusion.
An abdominal X-ray was noncontributory and the stent was in situ. Computed tomographic
scan of the abdomen showed minimal fluid in the porta hepatis, right posterior perihepatic
region, and right perinephric region. Ultrasound-guided aspiration of fluid was bilious
and percutaneous drains were placed in the hepatorenal pouch and retroperitoneal collection.
Subsequently patient improved symptomatically. As the drain output significantly reduced
in the next few days, hepatorenal pouch drain was removed.
Fig. 1 Spyglass cholangioscopy picture of hilar stricture extending to left hepatic duct.
She had a recurrence of pain with rising inflammatory markers after drain removal.
An MRCP done showed focal hyper intensity from the common hepatic duct region reaching
up to perihepatic collection. Suspecting a biliary leak, she underwent a repeat ERCP
([Video 1]). After removing the left ductal stent, a cholangiogram was done that showed a leak
at the junction of right anterior and posterior hepatic ducts ([Fig. 2]). Right duct was cannulated first and 7 Fr and 5 Fr plastic stents were placed into
right anterior and posterior ducts, respectively. Subsequently, a 5 Fr plastic stent
was placed into left hepatic duct also ([Fig. 3]). Over the next few days, she improved symptomatically and was discharged. The histopathology
report of SpyBite biopsy showed fibrous tissue with atypical glands. After 6 weeks,
she underwent surgical excision of the extrahepatic biliary duct and Roux-en-Y hepaticojejunostomy
to right anterior, right posterior, and left hepatic ducts. Histopathology of excised
bile duct showed features of intraductal tubulopapillary neoplasm with no evidence
of invasion.
Video 1 Post-ERCP Bile Leak.
Fig. 2 Fluoroscopy image during endoscopic retrograde cholangiopancreatography showing the
site of bile leak at the junction of right anterior and posterior ducts (arrow).
Fig. 3 Post-endoscopic retrograde cholangiopancreatography fluoroscopy picture showing stents
in right anterior, right posterior, and left hepatic ducts.
Though complications are inherent during ERCP, bile duct injury leading to bile leak
is rare. We feel that the tapered tip cannula, which was forced to pass across the
stricture in right hepatic duct without attaining deep cannulation with the guidewire,
would have caused the bile duct injury. As per Stapfer classification, our patient
had a type III ERCP-related perforation. Type III ERCP perforations are ductal injuries
due to accessories used during ERCP.[1] These perforations can be managed conservatively with intravenous antibiotics and
biliary drainage.[2]
[3] Special caution has to be taken in high-risk cases to prevent bile duct injury.
The practice of over the guidewire cannulation, fluoroscopy guidance, and caution
at cannulation across strictures especially during stricture dilatation are of great
help in preventing such complications. The selection of guidewires is extremely important
and stiff guidewires may be avoided when attempting deep cannulation into the intrahepatic
duct across a stricture. Though post-ERCP bile leak is a rare complication, early
recognition with a high index of clinical suspicion and prompt management are the
key factors in minimizing morbidity and mortality.
